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Introduction
CHAPTER 67 Laser Resurfacing
Marc Z. Handler David J. Goldberg
SUMMARY
Skin resurfacing is a common aesthetic procedure, and can result in
improvement in rhytides, skin texture, dyspigmentation, and skin tightening.
Several laser and energy devices are available, and they can broadly be divided
into ablative nonfractional lasers, nonablative nonfractional lasers, ablative fractional lasers, and nonablative fractional lasers.
Beginner Tips
There is generally a tradeoff between efficacy, or number of required treatments, and
the amount of downtime that a patient can expect.
Ablative nonfractional lasers have the most dramatic effect for resurfacing, but also
the greatest downtime. At the other end of the spectrum are nonablative fractional lasers, which require the most treatments but have the least downtime.
Expert Tips
Closely overlapping fractional laser pulses can lead to the MTZs blending together,
resulting in a nonfractional result.
Needed treatment energy and density is not uniform across the face; select areas may
require increased fluence or an increased density.
Donโt Forget!
Ablative nonfractional lasers may lead to dramatic improvement after a single
treatment, but other approaches generally require a series of multiple treatments.
When combining PDL or IPL and resurfacing lasers, be sure to treat for erythema
before resurfacing so that the immediate postprocedure erythema is not the target of the PDL or IPL.
Pitfalls and Cautions
Ablative nonfractional lasers should generally not be used in skin types V to VI, given
the risk of dyspigmentation and scarring.
The rate of acneiform eruptions and milia formation for laser resurfacing remains
fairly high, and this should be discussed with patients preprocedure.
Patient Education Points
For all treatments other than ablative nonfractional lasers, patients should be told to
expect several treatment sessions before seeing meaningful results.
Patients should have realistic expectations regarding the healing process, and should
be warned that they will be out of commission for up to 2 weeks with ablative nonfractional lasers.
Billing Pearls
Almost all insurers in the United States exclude laser treatments from coverage.
Patients may benefit from committing to a series of treatments, as this may allow
significant cost savings.
Pretreatment with occluded topical anesthesia can be started at home, and prescription
plans may cover the cost of this medication.
CHAPTER 67 Laser Resurfacing
INTRODUCTION
Skin resurfacing with energy-based devices decreases dyspigmentation, reduces rhytides and improves texture. Tighter skin is made possible through thermal damage to dermal collagen bundles and stimulation of dermal fibroblasts. In order to produce dermal collagen damage, energy is transmitted through the epidermis and into the dermis at a minimum temperature of 65ยฐC, the temperature required to damage collagen.
Originally, energy devices required destruction of the epidermis along with the dermis. These ablative nonfractionated lasers are effective at collagen destruction, but also cause full epidermal destruction, requiring a significant recuperation period. Lasers that do not destroy the epidermis, but produce heat in the dermis, are referred to as nonablative lasers. They do not require the same duration of recovery, but necessitate a greater number of treatments to achieve appreciable results. The abbreviated recovery time following fractionated laser resurfacing reflects the creation of microscopic treatment zones (MTZs) that allow faster epidermal healing while thermally heating dermal collagen. Radiofrequency (RF) devices are not lasers, but utilize the same premise as resurfacing laser devices. Utilizing RF, the dermis is heated to a temperature that damages collagen and stimulates fibroblasts, while avoiding epidermal destruction. Each energy-based device has benefits and drawbacks. One device may produce faster results but require extensive downtime, while another may have an increased risk of hypopigmentation when used to treat a patient with a darker skin type.